Insertion of an intrauterine contraceptive device after induced or spontaneous abortion: a review of the evidence

doi:10.1016/S0306-5456(01)00264-9

British Journal of Obstetrics and Gynaecology

Volume 108, Issue 11, November 2001, Pages 1168-1173

British Journal of O...

https://doi.org/10.1016/S0306-5456(01)00264-9 Get rights and content

Abstract

Objective Assess the safety and efficacy of intrauterine contraceptive device (IUCD) insertion immediately after induced or spontaneous abortion.

Design Systematic search for randomised trials that had at least one treatment arm that involved IUCD insertion immediately after an induced or spontaneous miscarriage using Medline, Popline, EMBASE, and review articles supplemented by correspondence with investigators.

Population Women of any age or gravidity who had an IUCD inserted immediately after evacuation for spontaneous or induced abortion.

Methods Articles were abstracted and the raw data from tables were analysed with RevMan 3.1 software. We focused on Tietze-Potter gross life table probabilities with denominators of person-time of exposure.

Main outcome measures Rates of perforation, expulsion, pelvic inflammatory disease, contraceptive failure, and method continuation.

Results Complication rates for immediate post-abortal IUCD insertion were low. Perforation was rare with a rate of approximately one per 1000 insertions. One year gross cumulative expulsion rates ranged from 1.8% to 12.6%, pregnancy rates from 0.6% to 2.1%, and continuation rates from 54% to 90%. The net discontinuation rate due to pelvic inflammatory disease was low, ranging from 0.0 to 0.8 per 100 women at one year. Increasing gestational age at insertion was associated with increased expulsion rates.

Conclusions Post-abortal IUCD insertion is safe and effective. The risks of perforation, expulsion, pelvic inflammatory disease and contraceptive failure were low and similar to those reported for interval insertion. Second trimester gestational age is associated with an increased risk of expulsion. Immediate insertion may have a higher expulsion rate than delayed insertion. However, these risks may be outweighed by the benefit of immediate contraception.

Introduction

For those women who choose an intrauterine contraceptive device (IUCD) as their post-abortal method of contraception, immediate insertion has many benefits compared with later insertion. Ovulation returns soon after abortion, with half of women ovulating by 21 days after the procedure¹. Immediate post-abortal insertion provides immediate contraceptive protection. Furthermore, the woman avoids the potential inconvenience, discomfort and bleeding of a separate insertion procedure. Finally, her motivation for contraception is often high.

However, clinicians have feared that rates of IUCD perforation and expulsion may be higher in the post-abortal uterus due to its softness and enlargement. Immediate post-abortal IUCD insertion may increase the risk of upper genital tract infection after abortion. Finally, the contraceptive efficacy of the IUCD after post-abortal insertion and the method continuation rate are unclear. The purpose of this review was to assess the safety and efficacy of immediate post-abortal IUCD insertion.

Section snippets

METHODS

We performed a systematic search of the literature for randomised controlled trials that had at least one treatment arm that involved IUCD insertion immediately after an induced or spontaneous abortion using Medline, Popline, the Cochrane Controlled Trials Register and EMBASE, complemented by review articles and contacts with the investigators. We used the following key word combinations: (post-abortal IUCD insertions or IUD or IUCD or intrauterine devices) and (post-abortion or post-abortal or

Results

Eight trials met our inclusion criteria (Table 1). Overall, the two WHO studies were the largest and best, with 4476 woman-years of data6., 11.. They used standardised definitions and explicit reporting of outcomes. They reported their results in net (competing) cumulative rates. Each trial compared three devices (TCu 220C, Lippes Loop D, Copper 7), the first in the setting of insertion after induced surgical abortion⁶, the second after curettage for miscarriage¹¹. We derived the following

Discussion

Post-abortal IUCD insertion is both safe and effective. The absolute rates of perforation, expulsion, upper genital tract infection, contraceptive failure and method discontinuation were all low. These rates are comparable to those reported for interval IUCD insertion with modern copper devices18., 19., 20., 21., 22., 23.. Overall, devices with copper had lower pregnancy rates than those without copper, and devices with a ‘T’ shape had lower expulsion rates compared with other shapes. The risk

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Cited by (31)

Immediate Intrauterine Device Insertion Following Surgical Abortion
2015, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
These studies reinforce the importance of weighing the increased risk of expulsion against the risk of repeat unplanned pregnancy. The risk of IUD expulsion appears to be higher with immediate postabortion placement compared with interval placement, although reported expulsion rates in studies vary.7–11,13 For interval IUD placement, expulsion risk is most commonly estimated to be 5%, although studies report anywhere between a 2% and 10% expulsion rate.14
Contraception following abortion and the treatment of incomplete abortion
2014, International Journal of Gynecology and Obstetrics
Family planning counseling and the provision of postabortion contraception should be an integrated part of abortion and postabortion care to help women avoid another unplanned pregnancy and a repeat abortion. Postabortion contraception is significantly more effective in preventing repeat unintended pregnancy and abortion when it is provided before women leave the healthcare facility where they received abortion care, and when the chosen method is a long-acting reversible contraceptive (LARC) method. This article provides evidence supporting these two critical aspects of postabortion contraception. It suggests that gynecologists and obstetricians have an ethical obligation to do everything necessary to ensure that postabortion contraception, with a focus on LARC methods, becomes an integral part of abortion and postabortion care, in line with the recommendations of the International Federation of Gynecology and Obstetrics and of several other organizations.
Can ultrasound predict IUD expulsion after medical abortion?
2014, Contraception
Our randomized trial compared early and delayed intrauterine device (IUD) insertion following medical abortion. In this planned substudy, we explore if endometrial thickness and initial IUD position were associated with IUD expulsion. We also describe IUD movement within the uterus during the 6 months after insertion.
We recruited women undergoing medical abortion and choosing the copper IUD for contraception (n = 156). Participants were randomly assigned to early insertion 1 week after mifepristone or delayed insertion 4–6 weeks later. We measured endometrial thickness by transvaginal sonogram 1 week after abortion and IUD distance from the fundal aspect of the endometrial cavity three times: at insertion, 6–8 weeks later and at 6 months.
We analyzed endometrial thickness in 113 women, baseline IUD position in 114 women and IUD movement in 65 women. Women who expelled IUDs (n = 15) had slightly thicker endometria (p = .007) and slightly lower baseline IUD positions (p = .03) than those who retained IUDs, but no clear cutoffs emerged in the receiver operating characteristic curve analysis. Retained IUDs commonly moved up and down throughout the 6 months (from 14 mm towards the fundus to 32 mm towards the cervix). Overall, retained IUDs moved a median of 2 mm towards the cervix between insertion and exit (p < .0001).
After medical abortion, the risk of IUD expulsion increases with thicker endometria and lower baseline position. Since no clear cutoffs emerged in the analysis and expulsion remained uncommon even with thicker endometria, we do not recommend restricting IUD insertion based on ultrasound data.
Copper T IUDs often move within the uterus without expelling. Expulsion is uncommon, and we do not recommend restricting IUD insertion based on ultrasound data.
Group versus individual family planning counseling in Ghana: A randomized, noninferiority trial
2013, Contraception
Group, rather than individual, family planning counseling has the potential to increase family planning knowledge and use through more efficient use of limited human resources.
A randomized, noninferiority study design was utilized to identify whether group family planning counseling is as effective as individual family planning counseling in Ghana. Female gynecology patients were enrolled from two teaching hospitals in Ghana in June and July 2008. Patients were randomized to receive either group or individual family planning counseling. The primary outcome in this study was change in modern contraceptive method knowledge. Changes in family planning use intention before and after the intervention and intended method type were also explored.
Comparisons between the two study arms suggest that randomization was successful. The difference in change in modern contraceptive methods known from baseline to follow-up between the two study arms (group–individual), adjusted for study site, was − 0.21, (95% confidence interval: − 0.53 to 0.12) suggesting no difference between the two arms.
Group family planning counseling was as effective as individual family planning counseling in increasing modern contraceptive knowledge among female gynecology patients in Ghana.
Rates of continuation and satisfaction of immediate intrauterine device insertion following first- or second-trimester surgical abortion: A French prospective cohort study
2013, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Women who receive an IUD immediately after surgical abortion experience few complications and are less likely to have an unintended pregnancy than those who delay getting an IUD by several weeks [12,13]. Multiple studies have shown that immediate IUD insertion following abortion has complication rates similar to those reported for interval insertion [5–7]. Abortions present a considerable economic burden on society.
Immediate postsurgical abortion insertion of intrauterine devices (IUDs) could substantially reduce the risk of repeat abortion. Studies have demonstrated efficacy and safety, and postabortum insertion would likely increase rates of usage. There are few data in the literature concerning rates of continuation and satisfaction after immediate postabortion IUD insertion.
We performed a prospective cohort study of women undergoing surgical abortion and choosing immediate insertion of IUD for contraception. We followed at six months rates of continuation, expulsion, removal and pregnancy, and reasons for discontinuation of IUD postinsertion.
137 patients were included. At 6 months, we were able to contact 112 of them. The continuation rate was 78.6% (95% confidence intervals (CI) [69.8, 85.8]) and the satisfaction rate was high at 85.2% (95%CI [76.1, 91.1]). Three (2.7%) expulsions occurred. Removals occurred in 18.75%.
We found that women choosing immediate postsurgical abortion IUD insertion had high rates of continuation and satisfaction.
A multicenter comparative study of UCu200, TCu380A, and medicated γ-IUD devices inserted immediately after vacuum aspiration
2013, International Journal of Gynecology and Obstetrics
To compare safety and efficacy among 3 types of intrauterine device (IUD), namely UCu200, TCu380A, and medicated γ-IUD, when inserted after vacuum aspiration.
In a multicenter randomized comparative study, 1800 parous women requesting an IUD were enrolled in 12 centers across China in 2004–2005. The women received 1 of the 3 types of IUD and were followed-up for 12 months.
Among the participants, 596 received the UCu200, 591 received the TCu380A, and 594 received the medicated γ-IUD. No pregnancy occurred during the follow-up period. The expulsion rate was 4.13 per 100 women (95% confidence interval [CI], 0.83–5.75) for the UCu200, 5.16 (95% CI, 0.92–6.96) for the TCu380A, and 2.73 (95% CI, 0.67–4.05) for the medicated γ-IUD. The rate of medical removal of the UCu200, TCu380A, and medicated γ-IUD was 3.60 (95% CI, 0.77–5.11), 2.25 (95% CI, 0.62–3.46), and 1.02 (95% CI, 0.41–1.83), respectively.
Immediate insertion of the device after vacuum aspiration was found to be safe and effective for all 3 types of IUD. Compared with the other IUDs, the medicated γ-IUD had a lower rate of medical removal and might be the most appropriate for broad use.
www.chictr.org: ChiCTR-TRC-12002395

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Insertion of an intrauterine contraceptive device after induced or spontaneous abortion: a review of the evidence

Abstract

Introduction

Section snippets

METHODS

Results

Discussion

Contraception

Contraception

Am J Obstet Gynecol

Fertil Steril

Contraception

Contraception

Contraception

Contraception

Contraception

Contraception

Return of ovarian function after abortion

Clin Endocrinol